Guide to Pregnancy and its related disorders and complications. Tips for caring of your baby properly while in pregnancy and after pregnancy.

Infectious diseases may complicate pregnancy. It has been well publicized that an attack of German measles up to the ninth or tenth week of pregnancy may produce serious congenital malformations of the baby. If a pregnant woman has German measles or knows she has been exposed to the disease, she should consult her obstetrician immediately. Poliomyelitis is a serious complication of pregnancy, but easily averted by vaccination as directed by the doctor. Influenza vaccination, though not recommended for everybody in the population, is an important protection for the pregnant woman.

All States in this country require a serologic test for syphilis in pregnant women. This is done routinely from a blood specimen obtained at the time of pre-natal examination. People can have syphilis without knowing it. The disease can be a serious complication for the baby, or result in late miscarriage, pre­mature delivery, and even infant death. Syphilis discovered early in pregnancy can be cured readily with penicillin.

Most women have been vaccinated against smallpox, diphtheria and whooping cough, and many have acquired immunity to measles and chickenpox, by recovery from these diseases. However, it is prudent to avoid direct exposure to childhood diseases such as mumps, scarlet fever, and others. These diseases may not directly affect the fetus, but high fever may result in premature labor and termination of the pregnancy.
A physician cannot anticipate every question that may come up during the nine months of pregnancy. The intelligent patient will call her doctor at any time of the day or night when she considers it necessary. If a long trip is contemplated, the doctor should be informed. Old-wives’ tales about pregnancy still persist, and the doctor can give reassurance about worrisome questions if they are asked. The keystone of modern obstetrics is continued observation of the patient throughout pregnancy. Most of the complications of pregnancy, associated in the past with lack of medical attention, can be prevented when the patient is seen at frequent intervals.

During the first six months the patient should be seen every three to four weeks; during the seventh month, every three weeks; during the eighth month, every two weeks; and during the last month, every week.

The first visit to the physician includes a physical examination and blood-urine tests. Thereafter, visits include discussion of problems that may have come up, a review of the patient’s progress, and a brief examination. This includes examination of the abdomen, listening for the fetal heart, palpating the size of the baby, and examination of a urine specimen. During the last month of pregnancy there is usually a weekly vaginal examination to determine the “ripening” of the neck of the uterus, the position of the baby, and the proximity of onset of labor.

At the present time there are four criteria for the presence of pregnancy. The first criterion is a positive reaction to a biological test for pregnancy.
Pregnancy Tests

Hormonal products of conception, present in the urine of pregnant women, have a remarkably stimulating effect on the ovaries of young mice. This is the basis of the Ascheim-Zondek or AZ Test for pregnancy, first described over 30 years ago. The test is first definitely positive about four weeks after fertilization takes place, or six weeks after the last menstrual period.

The test requires a specimen of the patient’s urine, taken first thing in the morning on awakening. Preferably the patient does not eat or drink after eight or nine p.m. the night before. The evening meal should be bland, without alcohol, drugs or seasoned foods which will leave products in the urine that can kill the test animals. Small amounts of urine are injected into mice over a three-day period. Pregnancy is indicated by obvious activity in ovaries of the mice. The test is most reliable, on the order of 95 to 98 per cent.

“Faster” tests have largely superseded the original AZ Test. The “rat test” and “rabbit test,” almost as reliable as the original mouse test, take about 24 hours instead of three days. In the past decade the “frog test,” performed in three to five hours, has become popular. These animal tests are usually performed with a urine specimen but they may be performed with blood. The latter can be done more promptly since it is not necessary to wait until early morning for a urine specimen. The frog test is usually more dependable when pregnancy is a little further advanced. It is advisable to wait until about seven weeks after the last menstrual period for the frog test, whereas the other animal tests are usually reliable about a week earlier.

A number of so-called agglutination tests which do not require the use of animals have recently been devised. These depend on reaction of an antibody against the hormone excreted by the developing placenta. If small clumped particles appear when the urine and the antibody are warmed together in a tube, pregnancy is indicated. These tests are easily performed but not quite so reliable as the animal tests.

A number of hormone preparations useful in diagnosing pregnancy are available. These are called progestins and are closely related to the natural hormone, progesterone, which is produced during every normal menstrual cycle. If one of these progestins is injected or given by mouth for four or five days, the patient, if not pregnant, will bleed two to seven days after the last dose. If she is pregnant there is no bleeding (called with­drawal bleeding), because her body and the early developing fetus are producing large amounts of progesterone, and the small amount given for the test does not significantly change the body level. In a non-pregnant woman, withdrawal of the progestin produces uterine bleeding just as occurs in a normal menstrual cycle. These compounds are not of the same degree of reliability as the biological tests for pregnancy.

Animal tests are very accurate, though an occasional doubtful result requires repetition. Usually, two or three animals are injected with the same urine specimen, and if all are “positive,” pregnancy is virtually certain. It is important to use a laboratory that performs these tests every day, since accuracy is reduced if technicians do the tests infrequently.

The second positive test for pregnancy is the presence of the fetal skeleton, shown by direct x-ray film of the abdomen. It takes about four months of pregnancy for sufficient calcification to occur to make the fetal skeleton visible on an x-ray film.

The third reliable indicator of pregnancy is fetal movements. The patient may “feel life” between the sixteenth and twentieth weeks. She may misinterpret intestinal and muscular activity as movements of the fetus, but the trained physician may easily discern definitive movements of the infant by palpating the abdomen of the patient.

The fourth indicator of pregnancy is the infant’s heartbeat, distinguishable at the eighteenth week (infrequently, the sixteenth week). With a stethoscope, the rapid fetal heart rate is easily distinguished from that of the mother.

Nausea and Vomiting

Nausea and vomiting appear in most pregnancies during the first three months. The nausea subsides after the third missed period. Women should com­plain about this nausea to their physicians, who can assure them that it is related only to changes in the body associated with early pregnancy.

Eating dried fruits in small amounts and keeping the stomach slightly coated with food frequently helps to control nausea. Dried crackers, biscuits, or stale rye bread may be helpful early in the morning. Frequently, nausea is made worse by late rising and a rush to get to one’s job. Relaxation and unhurried movements in the morning tend to minimize the nausea.

If nausea is severe, mild sedation may be helpful. At times, various antinausea drugs may provide relief when taken either orally or rectally, as directed by a physician. If the patient is not able to eat or drink for 24 hours, the doctor should be notified immediately.
Heartburn

Heartburn or burning pain in the area just below the ribs is frequent in the middle and later months of pregnancy. It is probably due to changes in the position of the stomach, related to the enlargement of the uterus, and to changes in acidity of the stomach. A quarter of a glass of skim milk will reduce the heartburn. Various standard antacid products may prove to be helpful, but bicarbonate of soda should be avoided because, although it will relieve heartburn, it can produce swelling of the entire body.

Spells of shortness of breath frequently occur in the later months of pregnancy, from pressure of the enlarging womb upon the diaphragm. This is not related to any disease of the lungs. Propping up the patient on two or three pillows frequently helps.
Flatulence or Intestinal

Flatulence or intestinal gas commonly occurs in pregnancy; the intestines are merely slowing down due to effects of hormones produced by the pregnancy. Discomfort may be reduced somewhat during pregnancy, by not consuming gas-forming foods such as cabbage, baked beans, cauliflower and broccoli.
Muscle Cramps

Muscle cramps are frequent, particularly in the lower extremities, about the calves and thighs. These are associated with changes in the mineral content of the muscles during pregnancy. Limiting the consumption of milk to one glass a day for a week may reduce the cramps.
Back Pain

Back pain is a common disorder. Back pain commonly occurs from changes induced by pregnancy. All the ligaments attached to bones become softened. The protruding abdomen and weakened abdominal muscles affect the posture or “stance” of the pregnant woman. Also, there are various neuromuscular relationships that may be affected by the advancing pregnancy.

Generally, the disturbing back pain can be lessened by good standing posture and sitting on hard well-shaped chairs rather than soft cushioned couches or chairs. Standard simple exercises of abdomen and back muscles ease the discomfort. The bed should have a hard mattress, perhaps even a board placed under the mattress. Frequent car riding may produce back pain. Hard backrests are available to support the back muscles and improve driving posture. Driving may have to be curtailed if back pain is very severe and none of these measures help. A light, well-fitted supporting garment may be used to improve posture in walking and sitting.
Sleeping Habits

Sleeping habits of the pregnant woman may be upset. Emotional factors, such as worrying that something is wrong with the baby or that the baby is not moving, may keep her from falling asleep readily. Reassurance is important and worries should be talked out with doctor. Sleeping as well as breathing is easier in the last months of pregnancy if two or three pillows are used to prop the patient. In the last six weeks of pregnancy it is wise not to eat too late in the evening or to eat too large a meal. Mild sleep-inducing medications may be given safely if the sleeplessness is severe.

The beneficial effects of reasonable amounts of physical exercise in promoting conditions favorable to dropping to sleep at night should not be overlooked.
Faintness

The pregnant woman may get light-headed and possibly faint at least once during her pregnancy. If a fainting spell comes on, lie down or bend the head down between the legs and dizziness and faintness will subside quickly. Some women worry that they will “pass out” while driving a car. However, unless fainting spells occur with great frequency, driving is usually not forbidden. Premonitory sensations give a chance to pull over to the side of the road and lie down with the head at seat level. Carry a lump of sugar or piece of hard candy, chew on this, and dizziness and faintness will usually disappear. Fainting spells are at their maximum between the third and sixth months of pregnancy and rarely occur later.
Varicose Veins

Varicose veins often appear in pregnancy. The simplest way to prevent worsening of the varicosities is not to use constricting garters or rolled socks about the legs. When resting, elevate the legs on another chair or couch. If the veins are extensive, full-length elastic stockings may be worn, particularly when standing or walking for extended periods of time. Elastic stockings should fit tightly and are best put on by raising the leg far above the body and rolling them on from the foot. If a vein becomes tender, reddened and swollen it may be the early onset of phlebitis and the doctor should be consulted promptly for proper care. Surgery for removal of varicose veins is usually not recommended during pregnancy.
Hemorrhoids

Hemorrhoids are quite common during pregnancy. Hemorrhoids are large veins about the opening of the rectum. Increased pressure of the enlarging abdomen and uterus tends to over distend these veins. They may protrude outside the anus and be aggravated by hard or infrequent bowel movements. These are best treated by additional rest during the day and by cold compresses of diluted witch hazel. Discomfort may be relieved by anesthetic ointments prescribed by the doctor. Occasionally, a small hemorrhoid may become thrombosed (develop a blood clot in it) and be very painful. The doctor should be consulted and he will promptly relieve the discomfort. Surgery for hemorrhoids is not indicated during pregnancy.
Vaginal Discharge

Vaginal discharge is quite frequent during pregnancy. Moisture about the vaginal entrance tends to increase as pregnancy progresses toward the time of delivery. There are two common causes for abnormal vaginal discharge. A fungus called monilia causes a white flow. This is treated by specific drugs, either anti fungal agents or gentian violet preparations. The other infection causes a foamy, bubbly discharge produced by trichomonas parasites. A new antitrichomonal drug which may be taken either by mouth or vaginally, is datively specific for eradication of this condition.
Vaginal Bleeding

Vaginal bleeding is quite frequently encountered during pregnancy. At the time of the first missed period, some staining and slight bleeding may be related to implantation of the fertilized egg in the wall of the uterus. This bleeding usually subsides in several days. If bleeding progresses it may be due to a threatened abortion and the doctor should be informed. Occasionally, bleeding is due to a benign growth at the neck of the uterus called a polyp, or by a softening of cervical tissue, called an erosion. This area bleeds easily on pressure. The doctor can control it. Occasionally, bleeding is produced by intercourse.
Exercise

Exercise is important during pregnancy. Walking for a mile or so is fine for the average pregnant woman, but a long hike of four or five hours would be overdoing it. Dancing in its milder and less vigorous forms may be recommended. Sports such as tennis, golfing, or swimming, for short periods of time, are good relaxation for patients who are accustomed to them. This is too much activity for the final two months of pregnancy. More strenuous activities which are hazardous or fraught with tumbles, such as ice skating, skiing, horseback riding, diving, aqualunging and water­skiing are to be avoided during pregnancy. Even the exercises recommended are not advisable if the pregnancy is complicated by bleeding or cramps. Every patient is an individual and the type of exercise good for her should be discussed with the physician.
Traveling

Traveling is not hazardous for the normal pregnant woman. Airplane transport in pressurized cabins is the easiest form of travel. Rail travel is a little more difficult because of continuous pounding. Automobile travel for long distances is even more strenuous than train travel. Trips by car should be limited to two to three hundred miles a day, with frequent breaks to get out of the car, move around, and rest. Of course, some complication may make it unwise for a particular pregnant woman to travel; if so, the doctor will advise her.

It is not unusual for a woman in the first six months or so of pregnancy to make a long trip to a distant part of the country or even to go abroad. In such case she should have the name of an obstetrician who practices at her destination. She can also communicate with her own doctor by long distance telephone. In the final five or six weeks of pregnancy she should stay within 30 miles, or about an hour’s easy traveling time, of the hospital.

Seat belts should be used at all times when driving or as a passenger in a car. The safety belt must not be placed high on the abdomen, but lower down, snug about the hipbones which can take the shock of a sudden stop.
Clothing

Clothing should not fit tightly. Purchase lightweight undergarments that may be worn in both warm and cool weather. There is no reason why usual undergarments - a two-way stretch, for example can’t be worn in the early months of pregnancy, until they become too tight. When backache becomes troublesome, maternity girdles usually give considerable relief. High heels are an extra hazard when the abdomen enlarges and balance is precarious at best. However, a short woman married to a tall man may feel ill at ease in flats, and for morale reasons she may be permitted to wear moderately high heels if she is aware of the dangers involved.
Drugs

Drugs should be used only for absolutely necessary reasons during pregnancy, particularly in the first three months when the vital structures and organs of the baby are being organized. The various antibiotics should not be used during pregnancy except for reasons the doctor considers compelling. Not only does the use of these drugs sometimes produce an annoying vaginal discharge, but strains of germs resistant to the drugs’ actions may emerge. Such infections in a newborn infant are serious. Any drugs to which the patient is sensitive should be noted and used with caution if at all during pregnancy.
Smoking

Smoking during pregnancy has occasioned some furor. There is statistical evidence that infants tend to be smaller and the incidence of prematurity greater if the mother smokes excessively. It may be cruel, and frequently futile, to forbid cigarettes entirely to a woman who is accustomed to them, but nothing but good can come from cutting consumption from a pack or two a day to perhaps a half dozen cigarettes.

All women should be screened for colonization with GBS from the vagina and rectum at 35 to 37 weeks gestation. A swab from the vagina and rectum is sent to the laboratory for culture. The only exceptions to this are women who have already demonstrated GBS in their urine during the current pregnancy or women who had a previous infant with invasive GBS disease.
Prophylaxis During Labor(preventive treatment with an antibiotic) is recommended in the following situations:

*

Previous child with invasive GBS disease.
*

GBS in the urine culture during this pregnancy.
*

Positive GBS screening culture during the current pregnancy, unless a planned cesarean delivery is performed, before the woman goes into labor and before her membranes have ruptured.
*

If the GBS status is not known because the culture wasn’t done or is incomplete(was done too recently for the colonization to be documented) or if the results are unknown for any other reason and any of the following circumstances exist:
*

Delivery before 37 weeks gestation.
*

The membranes have been ruptured for 18 hours or longer(even at greater than 37 weeks gestation).
*

A temperature develops in labor of 100.4° F or greater(38.0° C or greater) (this may require a different antibiotic therapy).

Prophylaxis During Labor(preventive treatment with an antibiotic) is not recommended in the following situations:

*

Previous pregnancy with a positive GBS screening culture(unless a culture was also positive during this pregnancy).
*

Planned cesarean delivery performed in the absence of labor or rupture of membranes(regardless of whether the GBS culture is positive or negative).
* Negative vaginal and rectal GBS screening culture in late pregnancy during the current pregnancy.

Antibiotics are given during labor through an intravenous line. A usual dosage schedule is penicillin G 5 million units for the first dose, then 2.5 million units every 4 hours until delivery. If a woman is known to be penicillin allergic, Cefazolin may be given if she is not considered to be at high risk for serious reaction(anaphylaxis). If she is at high risk for an anaphylactic reaction, then clindamycin or erythromycin may be used. All medications are given intravenously.

If the culture shows the organism to be resistant to these medications, then a very strong antibiotic is used, called vancomycin.

Two risks exist with this treatment:

1.

some women may have a potentially dangerous allergic reaction to penicillin, and
2.

the development of resistant organisms is possible with widespread treatment.

New Approaches

Currently, researchers are investigating two other approaches: the development of a vaccine against group B strep and the development of a rapid, easily available, and accurate screening test that could be performed in labor with immediate results. A screening test would identify the women who carry GBS at the time of delivery and reduce the overall number of women receiving treatment. Screening tests are currently available but not considered accurate enough to determine treatment to prevent newborn GBS infection.
Informed Consent

To allow for informed consent, women should know the following:

*

Approximately 1 in 200 newborns born to a mother colonized with GBS will develop GBS disease early in the newborn period.
*

The risk of a newborn’s acquiring GBS from a mother who tests positive for the organism is 29 times higher than the risk for a newborn whose mother had a negative prenatal culture.
*

The risk of a newborn’s acquiring GBS in a labor that is preterm or complicated by long duration of membrane rupture or fever is 7 times higher than the risk for newborns born without these labor complications.
*

Five to 20 percent of newborns infected with GBS Will die.
*

The treated woman’s risk of a mild allergic reaction to penicillin is 1 in 10.
*

The treated woman’s risk of a serious allergic reaction to penicillin is 1 in 10,000.
*

The risk of dying from an allergic reaction to penicillin is 1 in 100,000 treated women.
*

Treatment for GBS before labor is not effective in preventing newborn GBS disease.

What is in store for the pregnant woman on the verge of childbirth when she arrives at the hospital?

Usually she is escorted to her room and is given a complete shave and an enema. The latter makes her more comfortable in labor and frequently stimulates contractions to greater effectiveness. After preparation the patient is taken to her own room on the delivery floor where a nurse trained in the care of labor patients is in constant attendance. From time to time the obstetrician will drop in to do a rectal or vaginal examination to determine the progress of labor and whether any medication is needed for comfort.

The waiting period in the labor room ends when a small part of the baby’s head is visible at the entrance of the vagina, in a first pregnancy. The visible part of the head is usually about the size of a quarter or half dollar. However, a woman who has had children is taken to the delivery room with the onset of pushing sensations or when the cervix is dilated about four inches.
Delivery of The Baby

The delivery room is virtually the same as an operating room. There are anesthesia machines with tanks of gases. Everybody wears a cap, gown, and mask. The large table on which the patient lies on her back has stirrups to support the legs fully. Metal hand pieces or bars are available for the patient to push against during contractions. An overhead surgical light illuminates the birth area and an attached mirror allows the mother to watch the birth if she wishes.

As the patient’s legs are being put into the stirrups, the lower part of the table is slid under the remaining part and the patient’s vaginal area, lower abdomen and inner thighs are scrubbed with an antiseptic. The entire area is covered with a sheet with a window for the vaginal opening.

As the vagina becomes distended, the obstetrician usually does an episiotomy. This is an incision in the vaginal margin, done under local anesthesia. The purpose is to prevent the tearing of tissues as the baby’s head is extruded.

The baby’s head appears slowly during a contraction, with the face turned toward the floor. As the full head appears it rotates to the left or right. The shoulders are then born and the abdomen and lower extremities rapidly follow suit. Fluid remaining in the uterine cavity is expelled with a gush.

The baby, entering a world where it is “on its own” for the first time, begins to cry. Sometimes assistance is needed to initiate breathing. The umbilical cord is cut and the baby is placed in a heated crib. An identification tag identical to the one worn by the mother is placed on the baby’s wrist.

A resident physician who is present at delivery examines the baby thoroughly. He examines the heart, lungs, abdomen, eyes, nose, palate, notes if the rectum is open and, in boy babies, that the testicles are descended into the scrotum. A rubber bulb with a glass catheter is used to suck out the baby’s mouth, and frequently to draw fluid from the stomach to prevent it from being inadvertently inhaled into the baby’s lungs.

As Labor Nears

As pregnancy nears its end, there is natural concern about getting to the hospital in time and recognizing the signs of imminent events.

During the final weeks of pregnancy (thirty-eighth to fortieth weeks) there is frequently no increase in weight. Even the baby may seem to be preparing for his advent by some reduction of activity. The patient may notice an increased sense of well-being, less discomfort from heavy weight of the uterus, and more energy for her usual household activities.

Mild, fleeting, irregular uterine contractions coming every ten or 15 minutes or so and lasting ten or 15 seconds may be noted. Most women do not notice these mild contractions, but some feel slight pain, or occasional association with mild, transient low backache. If contractions come more frequently than every ten minutes, and last for 30 seconds, the obstetrician should be notified. It is advisable that neither fluids or solid food be taken once labor has begun.

A woman about to go into labor often notices the discharge of a mucus plug. This plug extrudes from the small remnant of the cervical canal which remains at the onset of labor, and when it is passed the surface of the fetal membranes is in direct contact with the vagina. Also, at the onset of labor there may be a discharge of clear watery material, which does not indicate rupture of the membranes but that rupture is imminent. A small amount of reddish or pink discharge known as “show” frequently indicates onset of labor.

Though contractions at tenminute intervals are a warning to inform the doctor, the real beginning of labor is measured from the onset of contractions which occur at five-minute intervals and last at least 30 seconds. In general, a woman whose office examinations have been normal can wait at home until 30­second contractions occur every five or six minutes. However, if she has given birth before, it is advisable to have her in the hospital when contractions occur at ten-minute intervals.

In some patients (ten to 20 per cent) the membranes rupture spontaneously. This speeds up the entire mechanism of labor. If the membranes rupture and labor does not commence in a few hours, the doctor should examine the patient to determine whether labor is in progress. In a first pregnancy, the cervix may be long and thick and take two or three days to thin out. This is called cervical effacement which precedes the onset of labor.

Decisions as to whether the patient may stay at home, in bed or up and about, or in a hospital where frequent nursing observations can be made, are of course made by one’s doctor. In a woman who has had more than one baby, labor usually commences from three to 25 hours after the membranes rupture.
Understanding Labor

It is important for a pregnant woman to have some understanding of the mech­anism of labor, which means “work” ­the bringing forth of a child.

Labor usually takes between six and 12 hours for a first baby, three to six hours in subsequent pregnancies. Labor under two hours, which is rare, is called very rapid labor and it is usually desirable to slow it down. A slow progressing type of labor is less likely to tear tissues than a fast labor.

The first stage of labor is the period from onset of dilation of the cervix, when complete thinning has taken place, to full dilation up to ten centimeters (one inch equals two and a half centimeters) to allow the baby’s head to go through. Usually the head is down in the pelvis at about the level of the spine, a landmark about midway down the pelvis.

Intensity of contractions usually increases as the first stage progresses. When the cervix is slightly dilated, contractions will be mild to moderate but toward the end of the first stage will be more severe. Severe contractions last 40 to 50 seconds at the most, compared to ten to 20 seconds early in the first stage. If the membranes have not ruptured by the time the cervix is dilated about two inches, the doctor will rupture them. This improves the quality of contractions and lessens the duration of labor.

Transition in labor is the stage when the cervix is almost fully dilated. There is a tendency, even though dilation is not complete, for feelings of pressure and pushing to occur during contractions.

The second stage of labor is the time between full dilation of the cervix and the birth of the baby. This lasts from 30 minutes to two hours for a first baby, and from five or ten to 30 minutes in subsequent deliveries. The infant is born at the end of the second stage.

The third stage of labor is the period between the birth of the baby and delivery of the placenta. This usually takes five to ten minutes but may last as long as half an hour. If the placenta has not separated in half an hour, the obstetrician removes it manually. This manual removal usually requires ten or 15 minutes of general anesthesia.

The technological ability to control your fertility gives you choices not available when your parents were born. The loosening of social restrictions in the areas of marriage and parenting also affords single men and women the opportunity to become parents. Regardless of whether you are married or single, the preparation to become a parent involves similar considerations and decisions. If you are in the process of deciding whether to have children, you need to take the time to evaluate your emotions, finances, and health.
Emotional Health

The first and foremost evaluation you should make in pregnancy planning is why you want to have a child: To fulfill an inner need to carry on the family? Out of loneliness? Can you care for this new human being in a loving and nurturing manner? Are you ready to make all the sacrifices necessary to bear and raise a child? You can prepare yourself for this change in your life in several ways. Reading about parenthood, taking classes, talking to parents of children of all ages, and joining a support group are all helpful forms of preparation. If you choose to adopt, you will find many support groups available to you as well.
Maternal Health

Before becoming pregnant, a woman should have a thorough medical examination. Preconception care should include assessment of possible pregnancy complications. Medical problems such as diabetes and high blood pressure should be discussed as should any genetic disorders that run in either family.
Paternal Health

It is common wisdom that mothers-to-be should steer clear of toxic chemicals that can cause birth defects. Even women who are trying to conceive are cautioned to avoid toxic environments and to eat a nourishing diet, to stop smoking and drinking alcohol, and to avoid most medications.

Now similar precautions are being urged for fathers-to­be. New research suggests that a man’s exposure to chemicals influences not only his ability to father a child but also the future health of his child. Fathers-to-be have been overlooked in the past for several reasons. Researchers assumed that the genetic damage leading to birth defects and other health problems always occurred while a child was in the mother’s womb. After all, they reasoned, that’s where embryonic and fetal development take place. Conventional medical wisdom also held that defective-looking sperm(those with misshapen heads, crooked tails, or retarded swimming ability) were incapable of fertilizing an egg.

Scientists have recently discovered that how sperm look has little to do with how they act. Misshapen sperm can penetrate an egg, and they do not necessarily carry defective genetic goods. Moreover, sperm that look healthy and swim well can be the true genetic culprits. DNA fluorescent markers have identified normal-looking, yet genetically flawed, sperm that carry too many or too few chromosomes. Fathers contribute the extra chromosome 21 in about 6 percent of children with Down syndrome, which causes mental retardation; the extra X chromosome in 50 percent of boys with Klinefelter’s syndrome, which causes abnormal sexual development; and the shortened chromosome 15 in about 85 percent of children with Prader-Willi syndrome, a disorder characterized by retardation and obesity.

Although some birth defects are caused by the random errors of nature, it now appears that some disorders can be traced to sperm damaged by chemicals. Sperm are naturally vulnerable to toxic assault and genetic damage. Many drugs and ingested chemicals can readily invade the testes from the bloodstream; others ambush sperm after they leave the testes and pass through the epididymides, where they mature and are stored. By one route or another, half of 100 chemicals studied so far (including by-products of cigarette smoke) apparently harm sperm.

Some researchers believe that Vitamin C is nature’s way of protecting sex cells from damage. Bad diets, exposure to toxic chemicals, cigarette smoking, and not enough foods rich in Vitamin C are probably the biggest culprits in sperm damage.
Financial Evolution

You also need to evaluate your finances. First check your medical insurance: Does it provide pregnancy benefits? If not, you can expect to pay between $1,500 and $5,000 for medical care during pregnancy and birth-and substantially more if complications arise. Both partners should find out about their employer’s policies concerning parental leave including length of leave available and conditions for returning to work.

Raising a child exacts a tremendous strain on most family’s finances. Expenses during the first year of life averaged $5,774 in 1990. The expense of raising a child from birth to 21 years of age is presently estimated to be over $250,000­ not including the cost of a college education!

The cost and availability of quality child care should also be considered. Prospective parents should realistically assess how much family assistance they can expect with a new baby as well as the availability of nonfamily child care. While you may be aware of the federal tax credit available for child care, you may not be aware of how little assistance it provides: between a maximum of $480 for one child in a family having income of over $28,000 to a maximum of $720 for one child in a family having income of under $10,000. A second child doubles the credit; but no further assistance is provided for a third child or more children. How much does full-time child care cost? It averages between $5,000 and $10,000 a year, depending on your location(urban areas tend to cost more).
Contingency Planning

A final consideration is how to provide for the child should something happen to you and your partner. If both of you were to die while the child is young, do you have relatives or close friends who would raise the child? If you have more than one child, would they have to be split up or could they be kept together? Unpleasant though it may be to think about, this sort of contingency planning is highly important. Children who lose their parents are usually heartbroken and confused. A prearranged plan of action may help smooth their transition into new families.

RU-486 A steroid hormone that induces abortion by blocking the action of progesterone. Testing in the United States began in late 1994.

Preconception care Medical care received prior to becoming pregnant that helps a woman assess and address potential maternal health.
What do You Think?

Do you think most parents plan when they will have their children? At what point in your life do you think you will be ready to take on the responsibilities of becoming a parent? What are your biggest concerns about parenthood?

Most women are anxious at times to know if they are pregnant. Difficulties of confirming pregnancy vary greatly from one patient to another. Some women walk into a doctor’s office and announce that they are pregnant. The evidence to them is perfectly obvious. They may complain of nausea, inability to eat a certain food or lack of morning appetite, or sudden distaste for cigarettes. Their menstrual period is several weeks late. They may have noticed an increase in breast size with a feeling of heaviness, darkening of the area surrounding the nipples, increased frequency of urination, and a feeling of heaviness in the pelvic area. Some have marked salivation - excess of saliva.

A “package” of all the above-mentioned symptoms would surely indicate to an anxious woman that she is probably pregnant. But to the physician these signs are not truly diagnostic of pregnancy.
Pain Relief in Childbirth

If the patient is well prepared and understands the mechanism of labor, effective results can usually be obtained with minimal amounts of pain-relieving agents. The physician assesses the progress of labor by frequent examinations and gives the medication most appropriate to the exact stage of labor the patient is in.

Barbiturates may be given orally or rectally early in labor to produce sleepiness and relaxation. After labor has progressed to cervical dilation of about two inches, various morphine derivatives can be used effectively. Meperidine is a popular agent which reduces the pain threshold and makes the patient more comfortable. She may even fall asleep between contractions and wake up during the contractions.

If contractions become more violent, and the patient is somewhat apprehensive, scopolamine may be used. Scopolamine (called “twilight sleep” many years ago) is an amnesic or memory suppressing drug. Adequate amounts of it abolish the patient’s memory of the pain of labor and delivery.

After the cervix has opened to seven or eight centimeters in the second stage of labor it is usually inadvisable to give sedation. Contractions then are less painful and there is a great desire to push or “bear down.” The pushing sensation is similar to having a bowel movement. A large amount of sedation at this stage may make pushing less effective and slow the progress of labor.

Erythroblastosis is a disease of newborn infants associated with the Rh blood factor. A blood factor is a physical substance which some people have in their blood and some do not. If a blood factor gets into the blood of a person who has not inherited it, it acts like a foreign protein, and the body creates antibodies that antagonize the factor, much the same as antibodies against measles viruses are built up to give immunity to measles. But some anti­bodies do not protect, but cause damage.

“Rh” gets its name from Rhesus monkeys, in which the factor was first discovered in 1940. About 85 per cent of women have the Rh factor and are Rh­positive or Rh+. The remainder are Rh-negative or RH-. If an Rh- mother and an Rh+ father conceive a baby, the fetus growing in the uterus produces Rh factor and some of it may pass into the mother’s bloodstream. In that case the mother produces an antibody that is hostile to the Rh factor which to her body is a foreign substance. This antibody may cross back to the baby with destructive action on its red blood cells. The extent of this destruction determines the severity of “Rh disease” or erythroblastosis.

Most Rh- women with Rh+ husbands can produce one or two healthy babies or even more. Usually Rh disease does not manifest itself until the third or subsequent pregnancy. The maternal and fetal circulations do not intermingle, and it is thought that the back-and-forth transfer of Rh factor and antibodies may be effected by “leaks” in minute capillaries.

Blood studies of pregnant women determine their Rh status. If a patient is Rh+ there is nothing to worry about. If she is Rh- and has an Rh+ husband, the physician is watchful of a possible complication in an existing or future pregnancy. Even so, the odds are quite favorable. About five per cent of Rh­mothers, or one out of twenty, will have a baby with Rh disease, and this usually happens in a third or later pregnancy. Some evaluation can be made by frequent measurement of Rh levels in the mother’s blood during the last two months of pregnancy. At the time of delivery a delicate test called the Coombs test may confirm the presence of erythroblastosis in the infant. If the disease is severe an exchange transfusion may be required at birth. This is done by replacing all the baby’s blood with appropriate fresh blood of a donor. Occasionally, if the baby is alive in the womb and Rh disease appears to be worsening, early delivery at the thirty-fifth week may be indicated. A baby with Rh disease who is born in good condition will be watched carefully in the first few days after birth for signs of jaundice which may be due to a delay in onset of the disease.

At present there is no way of preventing Rh disease other than to forbid matrimony to an Rh- woman and an Rh+ man, which a devoted couple would hardly tolerate. However, “Rh babies” are uncommon even among couples who theoretically could produce them, and many severely affected babies are being saved .

There are some other blood groups that may produce cross reactions somewhat similar to the Rh factor, but these are usually mild and disappear without requiring transfusions.

Twins present additional problems to the expectant mother, the obstetrician, and for that matter the father. The statistical chance of having twins is one to 92.

Identical twins (always of the same sex) develop from a single fertilized egg which divides in two early in its development. One identical twin is the mirror image of the other.

Fraternal twins originate from two separate eggs fertilized by two separate spermatozoa. The eggs arise from one or both ovaries, embed in the uterus separately, and grow independently. Fraternal twins may be of different sex and their relationship is no closer than that of brothers and sisters. They are more common (70 per cent) than identical twins.

Fraternal and identical twins cannot be positively identified from their appearance. The question can be settled at delivery by examination of the placenta and the membranes separating the twins. If two layers of membranes are present, the twins are identical; if four layers, they are fraternal. Also, study of their blood groups will usually distinguish the two types of twins. A tendency to produce fraternal twins (but not identical twins) seems to run in families.

Triplets occur about once in 9,000 births, quadruplets once in 500,000 births, and the odds against having quintuplets are about40million to one. Nevertheless, in 1963, thriving quintuplets were born to a family in South Dakota and another in Venezuela.

What makes a doctor suspect that a woman may have a twin or multiple pregnancy? For one thing, the uterus is usually much larger than expected for the stage of pregnancy. Rapid weight gain, sometimes ten pounds in three to four weeks, suggests possible twins. But these are only suspicions unless the obstetrician is able to feel two heads, two trunks, or to hear two independent fetal heartbeats. X-ray films which show two fetal skeletons clinch the diagnosis.

Multiple pregnancy is a weighty matter, notoriously uncomfortable. Labor usually begins about three weeks earlier than the expected date of delivery. Toxemia is a frequent but usually controllable complication of multiple pregnancy. Twins, individually, tend to be much smaller than a single-born infant. Twins at term may weigh five and a half to six pounds each, compared to seven to seven and a half pounds for a single infant.

The hazard to twins of very early labor and premature birth must always be kept in mind. Twins will be recognized relatively soon if the pregnant woman makes regular visits to her doctor, and not infrequently twins may be saved by simple measures to prevent prematurity.

Labor with twins tends to be long and slow. The large distended uterus does not contract with normal force. Usually the membranes of the lower twin will rupture, reducing the size of the uterus and improving uterine muscle contractions. Risks are slightly greater for the second twin. Occasionally the presence of twins is not known until the first baby is delivered and the uterus remains large and a second fetal heart is heard. In the very obese woman, or when the second baby is very small, or when the mother has had no prenatal care, twins may easily be overlooked by the doctor.

Several decades ago, some experts proposed that elimination of the stresses of labor by delivering all preterm babies by cesarean would increase the newborn survival rate. The rationale was that reduced stress on the infant’s head would reduce the possibility of bleeding into the skull. This complication, called intraventricular hemorrhage, is another major cause of death in premature newborns. The best evidence now shows that cesarean delivery does not prevent ventricular hemorrhage. The best currently available evidence does not support performing a cesarean if the only reason for the surgery is a premature infant. Of course, there are times when cesarean is performed for the same reasons as it is in mature babies.

Episiotomy is another procedure that has been advocated as a way of reducing stress on the skull of the immature fetus. Studies are not available to demonstrate whether this is beneficial. The resistance of the perineal muscles, through which the infant passes just as it leaves the vagina and which are cut with an episiotomy, is less than the resistance of the cervix and the vaginal muscles through which the infant has already passed. Despite a lack of definitive evidence, some experts recommend episiotomy for the delivery of preterm infants. Others recommend it only when there is resistance in these muscles, rarely seen except in women having a first baby. This is an area worth further research.

Most important for the premature infants is the presence at the birth of personnel skilled in resuscitation and care of premature infants. Whenever possible, the delivery should take place in a hospital with a neonatal intensive care unit and with constant attendance of physicians, nurse practitioners, and nurses who are knowledgeable in caring for these tiny infants. A staff member, or team of staff members, should be present in the delivery room whenever a premature baby is born, ready to provide expert care from the moment of birth.